What lessons that have been learnt following the tragic death of a patient while undergoing an operation

4.13   Deputy R.G. Le Hérissier of the Minister for Health and Social Services regarding lessons learnt following the death of a patient during an operation:

Would the Minister outline the lessons, if any, that have been learnt following the tragic death of a patient while undergoing an operation?

Senator J.L. Perchard (The Minister for Health and Social Services):

I am sure that all Members will join with me in expressing sadness at the unexpected death of Nurse Elizabeth Rourke following a routine surgical operation on 17th October 2006. I know she is remembered by her colleagues at the Jersey General Hospital with great affection. I am sure that all Members would also understand the predicament which many of the staff at the Jersey General Hospital have had to endure for the last 2 years. The staff during the criminal investigation have had to continue to provide a professional service to patients and clients, and yet have not been able to be informed about or talk about the circumstances which resulted in the death of their colleague. The General Hospital is proud of its record of providing health services to the people of the Island for countless generations. While the Hospital provides a high standard of healthcare to Islanders, the staff working there are professional people who understand that they must always strive to improve upon what they do. I assure Members there is no place for complacency in this department. Our surgical services were improved prior to 2006 with the development of the new Day Care Surgery unit at a cost of £7.6 million. At this time a £2.2 million refurbishment of the Central Sterilisation and Supplies Department at Five Oaks took place - significant investment. We hope to make further investments in the future, particularly if the recommendations of the independent review which will be carried out should identify further changes to be necessary. I do recognise that the improvements made in the past years and improvements which may be required in future years provide no comfort to Mr. Rourke's family. States Members need to be mindful of 3 actions which will take place in the coming weeks. The first, I am advised is that the Deputy Viscount will reconvene the inquest into the death of Mrs. Elizabeth Rourke. The second is the commissioning of an independently-led inquiry. This independent review is where there will be, to use the questioner's phrase "lessons to be learnt." The third is that an external review will consider whether the policies and procedures of my department might have been broken. If so; who might be accountable and what procedures were broken. States Members will appreciate I

cannot say anymore on this subject at this moment.

1. Deputy R.G. Le Hérissier:

Notwithstanding the excellent work and the sense of sadness we all feel about this, would the Minister confirm whether or not he is fully satisfied with the governance procedures in operation? Second, would he not say that for the Chief Executive to state the day after the court case that all procedures were validated was, at the very best, very unwise? Thirdly, would he not say in the constant confusion about responsibility and accountability that to announce an independent investigation is to totally miss the point?

Senator J.L. Perchard:

I find the first point of the 3 questions, and the third point of the 3 questions, raised by the questioner contradictory. We need to get to the bottom of this. We need to understand what has happened, and the only way to do that is to handle this through an independent, transparent, rigorous inquiry, and that is what I intend to do.

2. Deputy R.G. Le Hérissier:

Would the Minister confirm that he has abandoned the idea of an internal investigation because it will be people who themselves whose names, rightly or wrongly, have been besmirched will be conducting the inquiry?

Senator J.L. Perchard:

I will, if the questioner permits, be making a statement in about half an hour on this very subject.

3. Senator S. Syvret:

Could the Minister explain to the Assembly why were anxieties about the locum's abilities not passed on to all of her relevant colleagues? Also, why was the Medical Director appointed as the case manager when, in fact, he had been a key actor in the incident himself?

Senator J.L. Perchard:

Unlike the Senator, I am unaware of the actual facts surrounding this matter. I intend to pursue the facts of this case through an independent, rigorous inquiry and that will be seen to be transparent, open and just and I will presume nothing until the results of that inquiry are made public.

4. Deputy P.V.F. Le Claire:

Would the Minister, when he undertakes this independent inquiry, also undertake and provide to the Assembly full disclosure of what the findings are in these regards and also at some point in time explain to Members how contradictory answers are given to the media and then corrected when the media presents accurate information presented in court? How is it that the Chief Officers are saying one thing and then when confronted with evidence are then retracting those statements and saying something else?  But more importantly ...

The Deputy Bailiff :

That is your question then, Deputy .

Deputy P.V.F. Le Claire:

One last second, Sir. More importantly, if the policies are going to be checked to see if they are broken can they also be checked to see if they are robust?

Senator J.L. Perchard:

If the questioner is referring to an Evening Post report quoting different people saying different things, I will leave it at that.

Deputy P.V.F. Le Claire:

He did not answer the second part of my question which was, are these findings to be made transparently available, fully disclosed to States Members? Also ...

The Deputy Bailiff :

I think you asked whether they were robust.

Deputy P.V.F. Le Claire:

With respect, Sir, I did say that leading up to the robust part, which he did not answer either. Will his policies be investigated to see if they are robust and will the reports be issued unedited to States Members and the public?

Senator J.L. Perchard:

There will be a robust inquiry into all the circumstances surrounding the death of

Elizabeth Rourke. I can only repeat my intention to make this a transparent and open inquiry and there will be no hiding place for anybody.

5. Deputy R.G. Le Hérissier:

Can the Minister assure us that the self-restraint he has imposed upon himself is a policy he would wish imposed upon all managers, so no premature statements are made in these kinds of situations?

Senator J.L. Perchard:

I would be delighted to confirm that that will be made obvious when I make my

statement.